Nursing Investigation Results -

Pennsylvania Department of Health
WESLEY ENHANCED LIVING AT STAPELEY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For:

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WESLEY ENHANCED LIVING AT STAPELEY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on February 27, 2020, it was determined that Westley Enhanced Living at Stapeley, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.




 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observations, interviews with staff, and a review of facility documentation, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety.

Findings include:

A tour of the Food Service Department conducted at approximately 9:35 a.m. on February 27, 2020, with Employee E2, the Food Service Director (FSD), revealed the following concerns:

Observation in the receiving area behind the building revealed a dumpster with both lids open on the top of the dumpster.

Observation in the walk-in refrigerator revealed a temperature of 48 degrees on the internal thermometer. The door had been slightly ajar when we approached it.

Observation in the main kitchen revealed two sinks used for handwashing but no trash can nearby to throw the disposable paper towel. The FSD directed me to the other side of the kitchen under a prep table where the trash can had to be pulled out to remove the lid before discarding the paper towel.

Observation of the utensil rack on the wall in the kitchen revealed a build-up of dust and dirt where the clean kitchen utensils were stored after being washed and sanitized.

A tour of the second-floor kitchen area conducted at approximately 9:50 a.m. on February 27, 2020, with the FSD, revealed the following concerns:

Observation of the stainless-steel prep-tables and sink revealed a heavy build-up of dusty, dirt and food spatters on the legs and sides. The walls and baseboards were also dusty and dirty, especially in the corners. The door gaskets on the under-counter reach in freezer and refrigerators were cracked, dirty containing food particles and crumbs and were coming loose from the door frames.

Observation in the serving area adjacent to the dining room revealed soiled baseboards around the base of the counter and the cupboard where the juice machine was stored also had dusty and sticky surfaces.

A tour of the first-floor kitchen area conducted at approximately 10:00 a.m. on February 27, 2020, with the FSD, revealed the following concerns:

Observation of the walls and baseboards revealed that they were dusty and dirty, and the baseboard had come loose from the wall near the electric room door creating a crevice for insects. Further observation revealed the fan on the wall above a small griddle was dusty and dirty and had a viscous orange liquid dripping from the fan guard. The garbage disposer control box had a heavy build-up of dust and dirt on top, and the ice machine had dust, dirt and grime in the louvers on the front of the machine.

Observation in the serving area adjacent to the dining room revealed soiled and stained baseboards around the base of the counter. Observation of the cupboard where the juice machine was stored revealed had dusty and sticky surfaces, and the cupboard under the juice machine also has sticky surfaces, the base of the cabinet was cracked and peeling and there were several fruit flies flying around the inside of the cabinet.

Interview with the FSD at approximately 10:15 a.m. on February 27, 2020, confirmed the above findings.

A follow-up tour of the first-floor kitchen area conducted at approximately 1:00 p.m. on February 27, 2020, revealed a dietary aide, Employee E3, operating the dishwasher which was running showing that the highest wash temperature reached was 143 degrees. When asked where she logged the temperatures, she could not find the log and went to Employee E4, dietary aide, who found the form which had already been filled out by a third dietary aide who had left for the day. When asked what to do if the wash temperature was below 160 degrees they did not respond.

A follow-up tour of the second-floor kitchen area conducted at approximately 1:15 p.m. on February 27, 2020, revealed a dietary aide, Employee E5, operating the dishwasher which was running showing that the highest wash temperature reached was 133 degrees. When asked what the dishwasher temperatures should be, she stated that the wash should be 160 degrees and the rinse should be 180 degrees. Employee E5 then proceeded to turn off the machine and load all the dishes onto a cart and said she was taking them to the main kitchen to run them through the machine there.

Review of the Dishwasher Temperature Logs for January 2020 on the first floor revealed approximately 54% of the temperatures were listed below the 160 degrees for wash and 180 degrees for rinse temperatures, and on the second floor approximately 14% of the temperatures on the Dishwasher Temperature Logs for January 2020 were listed below the above standards.

An interview on February 2, 2020, at approximately 1:30 p.m. with Employee E2, the FSD confirmed the low dishwasher temperatures and he was going to call his dishwasher repair company.

A follow-up tour of the walk-in refrigerator in the main kitchen revealed a temperature of 49 degrees on the internal thermometer which was confirmed by Employee E1, the Nursing Home Administrator.

The facility failed to store and prepare food in accordance with professional standards for food service safety.


42 CFR 483.35(i) Food Procure, Store/Prepare/Serve-Sanitary

28 Pa. Code: 201.14(a) Responsibility of licensee

28 Pa. Code: 201.18(b)(3) Management

28 PA. Code: 207.2(a) Administrator's responsibility




 Plan of Correction - To be completed: 03/20/2020

A.
1. The open cardboard recycling dumpster lid was closed immediately. All utility staff members that take out the trash and recycling were re trained on the proper way to leave the area once finished.
2. The new closing mechanism for the walk in has been ordered and will be replaced ASAP. New thermometers have been installed throughout the walk in to ensure an accurate temperature. The one by the door has been removed due to being in an inaccurate area. Temperature logs are being monitored by sous chef and chef manager twice a day to ensure accurate temperatures and corrections if needed.
3. Hand washing sink foot operated trash cans have been purchased and installed by all handwashing sinks. They are monitored and emptied throughout the day for cleanliness and function.
4. The Utensil rack in the kitchen was immediately disassembled and washed. This has been put on the weekly cleaning list to ensure there is no dust or debris.
5. Second floor pantry was completely scrubbed including the table legs. The walls and baseboards have been scrubbed and will be replacing damaged baseboards and re painting as needed. Gaskets were cleaned and determined needed replacing. They have been ordered and will be replaced as soon as they arrive. All items have been added to daily and weekly cleaning lists will be checked by a manager prior to the end of each shift.
6. The cupboard below the juice machine along with the baseboards will be removed due to damage. Cleaning of the juice machine area has been added to the daily cleaning checklist.
7. The walls and baseboards have been scrubbed and will be re painted and all baseboard replaced. The fans in the kitchenettes have been added to the weekly cleaning schedule. The ice machine and garbage disposal were taken apart and cleaned thoroughly. They are on the daily and weekly cleaning lists.
8. All baseboards are all being replaced. The cupboard under the juice machine is being removed. The inside of the juice cabinet has been added to the daily cleaning checklist, and will be checked after each shift by a manager.
9. All dish machines were serviced later that day and repaired by our Ecolab representative. Heating elements were fixed and or replaced to ensure proper washing, rinsing temperatures are achieved. We are holding a mandatory inservice with all staff to review the proper dishwashing procedures and temperatures. All temperature logs will be reviewed after each meal by a manager to ensure they are correct. Any issues will be fixed immediately before continued use of the machine.
B.
Dining managers will be visiting all areas of receiving, storage and service multiple times a day to observe and correct any issues. They will be monitoring logs and spot checking them to ensure correct documentation and corrective actions are being taken. While documenting any issues and bringing them to the GM's attention immediately.

C.
The managers daily work flow includes all areas and will be monitored by all managers daily. Each manager will document their observations and corrective action and we will meet weekly to discuss trainings needed to prevent issues from coming up and to further educate staff. All managers will check all logs and initial them daily to ensure temperatures and cleaning assignments are being completed correctly.

D.
At our bi-weekly managers meeting we will discuss trends and reoccurring issues and come up with the proper training and in services needed to have the staff completing all tasks correctly and thoroughly. Managers will also discuss any maintenance issues they have seen or put work orders in for so that the GM can follow up on the status and making sure they are completed.
E. Results of audits will be reported through quarterly QA process x 3


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